FHIR MasterclassMark Braunstein, MD

Professor of the Practice

School of Interactive Computing

Georgia Institute of Technology

About Me

1963 …

1965…

1969…

DEC Flip Chip Modules …

A typical flip-chip module, the R111, had three 2-input nand gates -- $14

Core Memory …

12 33 x 33 planes = approximately 1630 bytes of memory -- $4680

Removable Disks …

Removable pack hard drive 30 MB -- $30,000

Paper “CCD” …

Early “PopHealth” …

Today …

Interoperability

Traditional: possessing the technical means to share diverse data among digital systems and tools

Open: ensuring that the data stored in digital health systems is freely available to end users and software developers rather than being restricted only to the vendor companies that created those systems

Contemporary Interoperability Spectrum

https://www.healthit.gov/sites/default/files/nationwide-interoperability-roadmap-draft-version-1.0.pdf

Traditional Interoperability Use Cases

Care Coordination Chronic Disease

“… while the average Medicare beneficiary sees between six and seven different physicians, beneficiaries with five or more chronic conditions see almost 14 different physicians in a year and average 37 physician visits annually. People with five or more chronic conditions fill almost 50 prescriptions in a year.”

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497638/pdf/15158105.pdf

Transitions of Care Medication Reconciliation

Courtesy: Qvera

“an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.”

Read a Joint Commission Publication on Medication Reconciliation

http://www.jointcommission.org/assets/1/6/tst_hoc_persp_08_12.pdf

Public Health Surveillance

CDC

Population Health Quality Measures

The Triple Aim (IHI):Improving the patient experience of care (including quality and satisfaction)Improving the health of populationsReducing the per capita cost of health care

http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx

https://www.osehra.org/popHealth

Typical “Retrospective” Architectures

Population Health popHealth

https://github.com/pophealth/popHealth/wiki

Federated

Regional Health Information Exchange IHIE

http://www.ihie.org/

Centralized

National EHR My Health Record

Centralized

Read About CMS’ Blue Button on FHIR Program

Global Research OHDSI

http://www.ohdsi.org/ Federated OMOP

Potential FHIR “Active” Architectures

http://pavelone.github.io/reveal.js/images/archi-draft.png

“Active”

http://www.hspconsortium.org/

“Active”

FHIR BACKGROUND

HL7 Standards Evolution

http://www.hl7.org/

Messaging -> Documents/Modeling -> Workable Interoperability

HL7 101

MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4<cr>PID|||555-44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520<cr>OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730||||||||| 555-55-5555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD<cr> OBX|1|SN|1554-5^GLUCOSE^POST 12H CFST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F<cr>

HL7 V2 Message

Glucose level (normal ranges)

LOINC 1554-5 Glucose [Mass/volume] in Serum or Plasma --12 hours fasting

http://wiki.hl7.org/index.php?title=Examples_section_of_the_v3Guide#The_V2.4_Message

MSH – HeaderPID – Patient IdentifierOBR – Observation RequestOBX – Observation Result

<observationEvent><id root="2.16.840.1.113883.19.1122.4" extension="1045813"

assigningAuthorityName="GHH LAB Filler Orders"/><code code="1554-5" codeSystemName="LN"

codeSystem="2.16.840.1.113883.6.1"displayName="GLUCOSE^POST 12H CFST:MCNC:PT:SER/PLAS:QN"/>

<statusCode code="completed"/><effectiveTime value="200202150730"/><priorityCode code="R"/><confidentialityCode code="N"

codeSystem="2.16.840.1.113883.5.25"/><value xsi:type="PQ" value="182" unit="mg/dL"/><interpretationCode code="H"/><referenceRange>

<interpretationRange><value xsi:type="IVL_PQ"><low value="70" unit="mg/dL"/><high value="105" unit="mg/dL"/>

</value><interpretationCode code="N"/>

</interpretationRange></referenceRange>

HL7 V3 Domain Content

Glucose level (normal ranges)

LOINC 1554-5 Glucose [Mass/volume] in Serum or Plasma --12 hours fasting

http://wiki.hl7.org/index.php?title=Examples_section_of_the_v3Guide#The_v3_Message_-_Domain_Content

Transmission WrapperTrigger Event Control Act wrapperDomain Content

HL7 Clinical Document Architecture (CDA)

Complex XML schemaRenderableNot composable

1. Open Alma Deleon CCD with Text Viewer Program2. Copy and paste into XML Input Box3. Click Tree View

https://www.linkedin.com/pulse/connecting-ios-your-emr-using-healthkit-cda-part-three-eric-whitley

Entry Level TemplateFamily History

SNOMED Disease

ICD9 Migraine

EntryRelationship: One of several elements used to connect clinical act statements to each other.

Observation: An act that is intended to result in new information about a subject.

Document Template

Section Template

From RIM

RIM Core Structural Attributes

“a static model of health and healthcare information as viewed within the scope of HL7 standards development activities”

HL7 Woody Beeler

Innovative CDA Rendering

View the V3 Administrative Gender Value Set in JSON

FHIR Links to V2 and V3

CDA -> FHIR

Matt Spielman shreds a CCDA document into FHIR resources using InterSystems’ HealthSharehttps://twitter.com/DocOnFHIR

FHIR Resources

0 - 5

3: has been verified as meeting the DSTU Quality Guidelines and has been subject to a round of formal balloting with at least 10 implementer comments drawn from at least 3 organizations resulting in at least one substantive change

Maturity

FHIR Observation Resource

Incorporates existingdata standards

IDs unique to eachFHIR server

{"resourceType": "Observation","id": "152896","meta": {

"versionId": "1","lastUpdated": "2016-09-30T10:32:52.116-04:00"

},"text": {

"status": "generated","div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Heart Rate, 71 bpm</div>"

},"status": "final","code": {

"coding": [{

"system": "http://loinc.org","code": "8867-4"

}],"text": "Heart Rate"

},"subject": {

"reference": "Patient/152860"},"encounter": {

"reference": "Encounter/152862"},"effectiveDateTime": "2016-09-23T10:33:40-04:00","valueQuantity": {

"value": 71,"unit": "bpm"

}}

Resource ID on this FHIR server

Human readable text

http://docs.smarthealthit.org/fred/

Renderable

Copy and paste me into SMART FRED V0.4

Try It

Note the Extensions for US Core Race, Ethnicity and Religion

1) Open diana prince.txt2) Copy and paste into the Open Resource box3) Click Load JSON

Composable

FHIR API -> FHIR Adapter -> OMOP Data Model -> Synthetic Patient Data

Find Marla

Click hereClick on Patient ResourceSearch for Family Name “Dixon”Find “Marla”Note her ID

FHIR Bundle

What’s Marla’s Body Weight (LOINC 3141-9)?

Click Here

ID: 523050

Compound Search

Find Her Medical Problems

Click Here

How many problems does Marla have?

Weight: 185 lbs

Find Her Medication Orders

Click Here

How many drugs should Marla be taking?Who is her doctor?

Problems: 4

Observation SearchSpecification

https://www.hl7.org/

Population Search

Patients who live in Detroit

Exercise:

Try New York

How many patients?

https://demo.bbonfhir.com/

Complexity Goldilocks Problem

How Many?How Detailed?

https://www.hl7.org/

http://projects.iq.harvard.edu/fhirgenomics

Genomics Resource

Metadata

Other Challenging Resource Sub-domains

Media Imaging

mHealth

Try it as homework!

http://www.cccblog.org/2011/04/26/toward-an-open-mhealth-ecosystem/

{"systolic_blood_pressure": {

"value": 160,"unit": "mmHg"

},"diastolic_blood_pressure": {

"value": 60,"unit": "mmHg"

},"effective_time_frame": {

"time_interval": {"start_date_time": "2013-02-05T07:25:00Z","end_date_time": "2013-06-05T07:25:00Z"

}},"body_posture": "sitting","descriptive_statistic": "maximum"

}

Native FHIR output?What data?Mean/max/min?Result Interpretation?

{"id": "5510259685cc310900f67753","userId": "52e20cb2fff56aac62000001","startTime": "2015-03-23T14:29:34.000Z","endTime": "2015-03-23T14:30:17.000Z","tzOffset": "-04:00","type": "walking","source": "moves","duration": 43,"distance": 29,"steps": 57,"calories": 0,"sourceData": {"manual": false

}

Duke Maps CCD to Apple’s HealthKit

Codes, Value Sets, Profiles

1) CODE SET: The terminology (SNOMED, LOINC)

2) VALUE SET: Subset for a specific purpose (ED visit)

3) ELEMENT DEFINITION: Binds an element ofthe resource to a Value Set in a specific Profile

4) SPECIFIC RESOURCE INSTANCE: Has a value from the terminology and claims to be conformant to the profile (via the element definition)

Code and Value Sets

https://fhirblog.com/2015/06/23/terminology-services-in-fhir/

{"system": "http://loinc.org","code": "8867-4"

}

Remember LOINC?

Profile

clinfhir

Observation Resource Specification

https://www.hl7.org/

Profiles

Value Set

US DAF Profile

https://www.hl7.org/

The DAF Initiative tries to leverage the HL7 FHIR, C-CDA and existing IHE standards to standardize access to Meaningful Use Stage 2 structured information both within the organization and from external organizations.

Conformance

Provides for a degree of automatic configuration and adaptation

Automation connects to all the detailed statements of functionality, such as StructureDefinitions (Profiles) and ValueSets

Human-readable content that can minimize the need for direct communication between the operators of the systems being configured to interoperate

FHIR Paradigms

REST Small, light-weight exchanges with low

coupling between systems

Messages Communicate multiple resources in a single

exchange

Documents Focus is on persistence when data spans

multiple resources

Services Use a custom service when capabilities of

other paradigms don’t fit requirement

https://www.hl7.org/

FHIR REST API

https://www.hl7.org/

CreateReadUpdateDelete

FHIR Document

https://www.hl7.org/

FHIR Message

https://www.hl7.org/

Content/Resource Format Always the Same

https://www.hl7.org/

Resource References

Classic coding system issue

https://www.hl7.org/

Narrative

Optional HTML representation of resource content - clinical safety issue, fall back option

https://www.hl7.org/

Useable at Many Levels

Personal: Social media and mobile applications

Provider: Clinical workflow/process, decision support applications

Institutional: Data exchange between systems

Regional: Health information organizations (HIEs)

National: Health hubs or EHRs (e.g. My Health Record)

Provider facing

Patient facing

http://jamia.oxfordjournals.org/content/early/2016/02/16/jamia.ocv189

Open Health Apps SMART on FHIR

Developed by Anyone

Work with Any EHRhttp://slideplayer.com/slide/4583873/

https://gallery.smarthealthit.org/

Two Key Clinical Use Cases

Clinical Decision Support

More accurate diagnosis, more appropriate treatment, personalized/precision medicine

EHR Enhancement

Improved data collection, visualization, workflow/process

Clinical Decision Support (CDS)

Tight-App EHR Integration

Courtesy: Cerner

Duke Medicine/Epic

creatinine := read {‘dam’="PDQRES2"};last_creat := read last {select "OBSRV_VALUE" from "LCR" where qualifier in ("CREATININE", "QUERY_OBSRV_ALL")};

Courtesy AMIA

Arden Syntax

1.0 ASTM 19922.0 HL7 19992.10 HL7 2013 (XML)3.0 Under Development

“FHIR element and extension identifiers would provide one mechanism for identifying the relevant data elements.”

https://www.hl7.org/fhir/comparison-other.html

Solves the “Curly Braces” Problem

I’ll demonstrate this later on!

CDS Hooks

Synchronous, workflow-triggered CDS calls returning information and suggestions

Launching a user-facing SMART app when CDS requires deeper interaction

Long-running, non-modal CDS sessions that observe EHR activity in progress

Try it! Treat Daniel Adams’ Osteoarthritis with Voltaren

Patient View

information card: text for the usersuggestion card: specific suggestion with an EHR button to accept it. Clicking populates the EHR.app link card: a SMART app, return to the EHR that re-triggers the CDS hook. This may result in different cards that may include decisions

For example, a user might launch a hypertension management app, and upon returning to the EHR’s prescription page the new blood pressure prescription is there.

Rx View

Explore the FHIR Resources (Homework)

{"resourceType": "MedicationOrder","dateWritten": "2016-09-29","status": "draft","patient": {

"reference": "Patient/1288992"},"dosageInstruction": [

{"doseQuantity": {

"value": 1,"system": "http://unitsofmeasure.org","code": "{pill}"

},"timing": {

"repeat": {"frequency": 1,"period": 1,"periodUnits": "d","boundsPeriod": {

"start": "2016-09-29","end": "2016-10-29"

}}

}}

],

"medicationCodeableConcept": {"text": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","coding": [{"display": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","system": "http://www.nlm.nih.gov/research/umls/rxnorm","code": "855928"

}]

},"reasonCodeableConcept": {"coding": [{"system": "http://snomed.info/sct","code": "396275006","display": "Osteoarthritis"

}],"text": "Osteoarthritis"

}}SMART Health IT — About CDS Hooks — Rx Demo source code

RxNorm CUI (Concept Unique Identifier)RxNorm has a REST api

Medication Coding

What Else Can You Do With 855928?

<properties><rxcui>855928</rxcui><name>Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]</name><synonym>Voltaren 75 MG Delayed Release Oral Tablet</synonym><tty>SBD</tty><language>ENG</language><suppress>N</suppress><umlscui>C0709155</umlscui></properties>

Is it safe in this patient? To find out, try this.

UMLS CUI

May Depend on What Else They’re Taking

{"rxcui":"83929","name":"abciximab","tty":"IN"},"sourceConceptItem":{"id":"DB00054,BTD00041,BIOD00041","name":"Abciximab","url":"http://www.drugbank.ca/drugs/DB00054#interactions"}}],"severity":"N/A","description":"Diclofenac may increase the anticoagulant activities of Abciximab."}

What does this drug do?

What is Abciximab? <rxclassdata><userInput><relaSource>NDFRT</relaSource><relas>may_treat</relas><rxcui>83929</rxcui></userInput><rxclassDrugInfoList><rxclassDrugInfo><minConcept><rxcui>83929</rxcui><name>abciximab</name><tty>IN</tty></minConcept><rxclassMinConceptItem><classId>N0000000408</classId><className>Angina, Unstable</className><classType>DISEASE</classType></rxclassMinConceptItem><rela>may_treat</rela><relaSource>NDFRT</relaSource></rxclassDrugInfo></rxclassDrugInfoList></rxclassdata>

Wikipedia:

“a platelet aggregation inhibitor mainly used during and after coronary artery procedures like angioplasty to prevent platelets from sticking together and causing thrombus (blood clot) formation within the coronary artery.”

{"resourceType": "MedicationOrder","dateWritten": "2016-09-29","status": "draft","patient": {"reference": "Patient/1288992"

},"dosageInstruction": [{"doseQuantity": {"value": 1,"system": "http://unitsofmeasure.org","code": "{pill}"

},"timing": {"repeat": {"frequency": 1,"period": 1,"periodUnits": "d","boundsPeriod": {

"start": "2016-09-29","end": "2016-10-29"

}}

}}

],

"medicationCodeableConcept": {"text": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","coding": [{"display": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","system": "http://www.nlm.nih.gov/research/umls/rxnorm","code": "855928"

}]

},"reasonCodeableConcept": {"coding": [{"system": "http://snomed.info/sct","code": "396275006","display": "Osteoarthritis"

}],"text": "Osteoarthritis"

}}SMART Health IT — About CDS Hooks — Rx Demo source code

A SNOMED-CT Clinical ConceptIHTDSO has a browser

Remember me!

ClinicalOntology

SNOMED CT is the ontological basis of the upcoming ICD-11.

{"resourceType": "MedicationOrder","dateWritten": "2016-09-29","status": "draft","patient": {"reference": "Patient/1288992"

},"dosageInstruction": [{"doseQuantity": {"value": 1,"system": "http://unitsofmeasure.org","code": "{pill}"

},"timing": {"repeat": {"frequency": 1,"period": 1,"periodUnits": "d","boundsPeriod": {

"start": "2016-09-29","end": "2016-10-29"

}}

}}

],

"medicationCodeableConcept": {"text": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","coding": [{"display": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet [Voltaren]","system": "http://www.nlm.nih.gov/research/umls/rxnorm","code": "855928"

}]

},"reasonCodeableConcept": {"coding": [{"system": "http://snomed.info/sct","code": "396275006","display": "Osteoarthritis"

}],"text": "Osteoarthritis"

}}SMART Health IT — About CDS Hooks — Rx Demo source code

A SNOMED-CT Clinical ConceptIHTSDO has a REST api

{"conceptId":"900000000000013009","defaultTerm":"Synonym (core metadata concept)","definitionStatus":"Primitive","statedDescendants":0,"inferredDescendants":0,"active":true,"effectiveTime":"20020131","module":"900000000000012004"},"lang":"en","term":"Degenerativepolyarthritis","length":26,"ics":{"conceptId":"900000000000020002","defaultTerm":"Only initial character case insensitive (core metadata concept)","definitionStatus":"Primitive","statedDescendants":0,"inferredDescendants":0,"active":true,"effectiveTime":"20020131","module":"900000000000012004"}

Remember me?

Australian Medications

CDS FHIR Apps Using Analytics

Therapeutic Clinical Decision Support

Courtesy: UCB

Experience with Prior Patients

Machine Learning

Hospital Discharge Decision Support

Model of Prior Patients

Public Health Decision Support

I49.9: Cardiac arrhythmia,

unspecified

Description: arrhythmia

Time: 1/5/16 02:05

Time to death: D−10m

Cardiac Arrhythmia 10 min

Complete Heart Block 3.3 hr

Giant cell arteritis with polymyalgia rheumatica 14 days

Experience with Prior Patients

Machine Learning

Genomics/Precision Medicine

CDS FHIR App Using Innovative Visualization

eICU Decision Support

CR

CR

Username: eicu_testingPass: !GTFHIREmory92

Let’s take a look!

EHR Usability, Workflow, Patient Engagement

Courtesy Geisinger Health Systemhttp://isalushealthcare.com/

Key Patient Use Cases

Engagement

Targeted education

Support for compliance

Continuous care

Compliance

https://gallery.smarthealthit.org/duke/pillbox

Compliance

Surescripts

Surescripts Compliance Resource

Courtesy Surescripts

You on FHIR (Homework)!

clinfhir.com

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Explore your Resources

End up with an Observation Resource

Note its LOINC Code

Find the LOINC browser

Find your LOINC code’s “fully specified name”

Problems FHIR Doesn’t Solve (yet)

Universal patient identifier (US, project underway)

Suboptimal health data (missing, inaccurate, noisy, etc.)

Dense data (images, intensive care, mHealth)

Support for population level analytics

Thank You!